Acute Management of Migraine in the Pediatric Emergency Room: A Scoping Review: An Abstract from Akron Children’s Hospital Resident and Fellow Academic Day

Akron Children’s Hospital had a total of 273 visits to the pediatric emergency department (ED) in 2025 alone, and though migraines are a frequent reason for ED visits, the approach to evaluation and management has an excess of variation. Supporting evidence can be found in a variety of study types. A clearer understanding of available pharmacologic options is needed to guide efficient and effective ED care. The objective of this scoping review is to summarize the evidence on pharmacologic treatments for acute migraine in children and adolescents presenting to the ED and identify the most beneficial. This scoping review followed established Arksey–O’Malley and PRISMA-ScR methods, with completion of the full PRISMA-ScR checklist and adherence to standardized guidelines. A PubMed search was developed with a manual review of all search strings with the use of AI-assistance for drafting and refining search terminology. Studies published in English from 2010–2025 that included children and adolescents up to age 21 years treated in an ED for acute migraine with pharmacologic intervention were eligible for review. Sources included randomized trials, prospective and retrospective cohorts, and systematic reviews. Case reports and gray literature were excluded from review. Three reviewers screened titles and abstracts; full texts were reviewed in duplicate, and data were extracted using a standardized form with independent verification. Outcomes, results, and key findings were summarized descriptively by medication class. The original search produced 93 records (after criteria were applied); 28 full texts were reviewed, and 16 studies met the final inclusion criteria (Table 1). Dopamine antagonists provide robust pain relief, high discharge rates, and outperform NSAID-only regimens for moderate to severe cases. Prochlorperazine appears non-inferior to metoclopramide with fewer extrapyramidal symptoms. Higher doses of ketorolac do not appear to provide better analgesia in pediatrics (maximum dose of 0.5 mg/kg or 15 mg). Further, compared to IV, intranasal ketorolac appears non-inferior for analgesia. Evidence supported ondansetron as a safe adjunct for the management of associated symptoms. Propofol and valproate appear to reduce pain in refractory cases, but evidence is limited. IV fluids alone had minimal impact on pain outcomes. Evidence most supports that dopamine antagonists (prochlorperazine, metoclopramide) and ketorolac are effective in the primary treatment of acute pediatric migraine in the ED. Propofol and valproate have shown potential benefit in refractory presentations. Overall, more high-quality comparative trials are needed to reduce practice variation and strengthen evidence-based ED treatment pathways.